Endometriosis-associated spontaneous major haemoperitoneum in pregnancy.

Spontaneous haemoperitoneum in pregnancy (SHiP) related to endometriosis is a rare and life-threatening complication. We report a case of a patient presenting to our department with major haemoperitoneum at 23+3 weeks of gestation due to a large rectovaginal endometriotic nodule. The patient required a midline laparotomy to evacuate 1 L of haemoperitoneum and achieve haemostasis. A large rectovaginal nodule was seen bleeding and was packed with haemostatic material and a large swab. After 24 hours, the swab was removed and haemostasis was confirmed. The patient was monitored very closely by a multidisciplinary team and the pregnancy was allowed to continue to try and achieve a better outcome for the baby and at 28 weeks of gestation, a girl was delivered in good condition via caesarean section.

Prehospital ultrasound scanning for abdominal free fluid detection in trauma patients: a systematic review and meta-analysis.

INTRODUCTION: Focused assessment with sonography for trauma helps detect abdominal free fluid. Prehospital ultrasound scanning is also important because the early diagnosis of hemoperitoneum may reduce the time to definitive treatment in the hospital. This study investigated whether prehospital ultrasound scanning can help detect abdominal free fluid. MATERIALS AND METHODS: In this systematic review, relevant databases were searched for studies investigating prehospital ultrasound examinations for abdominal free fluid in trauma patients. The prehospital ultrasound results were compared with computed tomography, surgery, or hospital ultrasound examination data. The pooled sensitivity and specificity values were analyzed using forest plots. The overall predictive power was calculated by the summary receiver operating characteristic curve. The quality of the included studies was assessed using the quality assessment of diagnostic accuracy studies tool. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was performed to assess the certainty of evidence. RESULT: This meta-analysis comprised six studies that included 1356 patients. The pooled sensitivity and specificity values were 0.596 (95% confidence interval [CI] = 0.345-0.822) and 0.970 (95% CI = 0.953-0.983), respectively. The pooled area under the summary receiver operating characteristic curve was 0.998. The quality assessment tool showed favorable results. In the GRADE analysis, the quality of evidence was very low for sensitivity and high for specificity when prehospital ultrasound was used for hemoperitoneum diagnosis. CONCLUSION: The specificity of abdominal free fluid detection using prehospital ultrasound examinations in trauma patients was very high.

Rare case of haemoperitoneum secondary to a ruptured ovarian ectopic pregnancy superimposed by a bleeding corpus luteum cyst.

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run.

Spontaneous haemoperitoneum in the second trimester of pregnancy.

This is a case of a spontaneous haemoperitoneum occurring in the second trimester of pregnancy which was managed with interventional radiology to avoid laparotomy and its potential consequences. We aim to raise awareness of this condition in pregnancy because the perinatal mortality rate is as high as 36%. Spontaneous haemoperitoneum in pregnancy (SHiP) has frequently been associated with vascular rupture from pre-existing endometriosis. Most cases of SHiP have been managed with laparotomy. However, transcatheter embolisation can impart lifesaving alternatives to more invasive interventions when caring for pregnant patients. More judicious use of imaging procedures may also help improve diagnostic and therapeutic pathways with SHiP. We recommend that high-risk pregnancies are managed in level IV regional perinatal healthcare centres, when possible, where subspecialists and alternative measures of management exist.

Adnexal arteriovenous malformation presenting with spontaneous massive haemoperitoneum.

Arteriovenous malformations (AVMs) are vascular anomalies composed of a tangle of abnormal vessels in which one or more feeding arteries are directly connected to one or more draining veins via a nidus with no intervening capillary bed. The adnexa are particularly rare sites for the formation of such malformations. Here, we present the case of a middle-aged woman who presented with spontaneous massive haemoperitoneum occurring as a result of a ruptured adnexal AVM. The diagnosis was suspected on transabdominal sonography and confirmed on CT angiography. The patient was shifted to the interventional radiology suite for an urgent angioembolisation following which she improved haemodynamically and her symptoms resolved. The case highlights the fact that although exceedingly rare, gonadal AVMs are an important cause of spontaneous intraperitoneal bleeding. Diagnostic and interventional radiology play an important role in the early and accurate diagnosis of this entity, and angioembolisation can be lifesaving in such patients.

Idiopathic omental hemorrhage: a case report and review of the literature.

BACKGROUND: A spontaneous rupture of an omental vessel can cause severe intraabdominal hemorrhage. We present a case of idiopathic omental hemorrhage caused by a vascular malformation. The literature is systematically reviewed. CASE PRESENTATION: A 65-year-old Iranian man was admitted to the emergency department for 10 days with abdominal pain. His medical history was not significant. Fever, vomiting, nausea, or anorexia were not reported. However, he was suffering from diaphoresis and malaise at the time. He did not smoke or drink alcohol. During physical examination, blood pressure was 82/60 mmHg with a temperature of 36.6 °C; heart rate was 96 beats/minute and respiratory rate was 18 breaths per/minute. An abdominal examination revealed mild tenderness in the periumblical. The focused assessment with sonography in trauma examination yielded positive results. The complete blood count showed 14 × 103/mcL of white blood cells and 185 × 103/mcL of platelets. The hemoglobin value was 6.7 g/L at admission. To stabilize the patient's condition, a unit of packed cell was administered. A double contrast enhancement abdominal computer tomography was performed, which revealed a massive hemoperitoneum. Subsequently, an exploratory laparoscopy was performed to search for the responsible pathology. But it was not successful. The surgical plan was changed to laparotomy. The hemorrhage source was not found during laparotomy. Observation revealed a massive hemoperitoneum originating in the omental vessels. A portion of the omentum located on the greater omentum at the greater curve was removed. Based on the pathological examination of the extracted tissue, vascular malformations were identified. The patient recovered uneventfully and was discharged from the hospital 7 days after surgery. Previous reports assessing idiopathic omental bleeding were systematically reviewed. A total of 14 hits were identified in PubMed and Scopus from 2015 to November 2022 for idiopathic omental bleeding. CONCLUSION: Presence of positive focused assessment with sonography in trauma, abdominal pain, imaging evidence of fluid accumulation, and a reduction in hemoglobin levels collectively indicate the likelihood of arteriovenous malformation occurrence. The treatment options include surgical intervention and transcatheter arterial embolization. Surgical intervention is recommended for subjects with hemodynamic instability, persistent hypotension and those whose diagnosis is unconfirmed.

Retrospective evaluation of the diagnostic utility of computed tomography in dogs with nontraumatic hemoperitoneum: 26 cases (2015-2020).

OBJECTIVE: To describe the appearance of lesions noted on abdominal computed tomography (CT) in dogs with spontaneous hemoperitoneum and determine the utility in using CT to differentiate benign from malignant lesions. DESIGN: Retrospective case series. SETTING: Single-center, university veterinary teaching emergency service. ANIMALS: Twenty-six dogs presented between 2015 and 2020 with spontaneous hemoperitoneum confirmed via abdominocentesis with pre- and postcontrast abdominal CT performed prior to surgery or euthanasia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: On histopathological diagnosis, 20 of 26 lesions were found to be malignant, and 6 of 26 were benign. Two radiologists reviewed the CTs. Radiologist 1 correctly identified 5 of 6 (83.3%) benign cases and 18 of 20 (90%) malignant cases. Radiologist 2 correctly identified 2 of 6 (33.3%) benign lesions and 18 of 20 (90%) malignant cases. Of the 10 imaging descriptors evaluated, none were significantly associated with the histological diagnosis. CONCLUSIONS: Results from the current study suggest that abdominal CT imaging of spontaneous hemoperitoneum cases is not a reliable indicator of malignancy versus benignancy. As such, prognosis should not be defined using this modality alone prior to emergency surgery and instead should be concluded based on the clinical course of the patient and histopathological findings of the resected tissues after surgery.

Using Deep Learning to Detect the Presence and Location of Hemoperitoneum on the Focused Assessment with Sonography in Trauma (FAST) Examination in Adults.

Abdominal ultrasonography has become an integral component of the evaluation of trauma patients. Internal hemorrhage can be rapidly diagnosed by finding free fluid with point-of-care ultrasound (POCUS) and expedite decisions to perform lifesaving interventions. However, the widespread clinical application of ultrasound is limited by the expertise required for image interpretation. This study aimed to develop a deep learning algorithm to identify the presence and location of hemoperitoneum on POCUS to assist novice clinicians in accurate interpretation of the Focused Assessment with Sonography in Trauma (FAST) exam. We analyzed right upper quadrant (RUQ) FAST exams obtained from 94 adult patients (44 confirmed hemoperitoneum) using the YoloV3 object detection algorithm. Exams were partitioned via fivefold stratified sampling for training, validation, and hold-out testing. We assessed each exam image-by-image using YoloV3 and determined hemoperitoneum presence for the exam using the detection with highest confidence score. We determined the detection threshold as the score that maximizes the geometric mean of sensitivity and specificity over the validation set. The algorithm had 95% sensitivity, 94% specificity, 95% accuracy, and 97% AUC over the test set, significantly outperforming three recent methods. The algorithm also exhibited strength in localization, while the detected box sizes varied with a 56% IOU averaged over positive cases. Image processing demonstrated only 57-ms latency, which is adequate for real-time use at the bedside. These results suggest that a deep learning algorithm can rapidly and accurately identify the presence and location of free fluid in the RUQ of the FAST exam in adult patients with hemoperitoneum.

Hemoperitoneum among Pediatric Abdominal Trauma Patients Visiting in Emergency Department of a Tertiary Care Centre: A Descriptive Cross-sectional study.

Introduction: Pediatric abdominal trauma presents a major challenge for first-line responders in the Emergency Department for assessment and management. The Focused assessment sonography for trauma is a readily available, easy-to-use, and affordable tool for detecting hemoperitoneum during the initial assessment of trauma in the Emergency Department for adult traumatic patients. The aim of this study was to find the prevalence of hemoperitoneum among pediatric abdominal trauma patients visiting the Emergency Department of tertiary care centre through Focused assessment with sonography for trauma examination technique. Methods: This was a descriptive cross-sectional study conducted in the Emergency Department of a tertiary care hospital from 7 April 2019 to 7 April 2020. Among 413 pediatric trauma patients, 93 children (1 to 17 years) admitted to the Emergency Department who underwent focused assessment with sonography for trauma examination were included in the study. Ethical approval was obtained from the Institutional Review Committee (Approval number: 111/19). Convenience sampling was used. Point estimate and 90% Confidence Interval were calculated. Results: Among 93 children receiving focused assessment with sonography for trauma imaging in the Emergency Department with a history of blunt abdominal trauma, the prevalence of hemoperitoneum was 18 (19.34%) (12.61-26.09, 90% Confidence Interval). Conclusions: The prevalence of hemoperitoneum was similar to other studies conducted in a similar setting. Keywords: blunt injuries; emergency medicine; focused assessment with sonography for trauma.

Hemoperitoneum due to rupture of intra-abdominal varices.

Portal hypertension, responsible for the formation of oesophageal varices, also generates intra-abdominal varicose dilations, especially of the perisplenic and mesenteric veins, which, like the oesophageal veins, are susceptible to rupturing and bleeding, in this case within the peritoneal cavity. However, the spontaneous rupture of these intraperitoneal varices is a rare complication, and poorly described in the literature. We present the case of a 72-year-old woman with CHILD B liver cirrhosis of unknown aetiology with portal hypertension on primary prophylaxis with carvedilol.

Ruptured subcapsular liver hematoma as a rare complication of HELLP syndrome. A therapeutic challenge.

HELLP syndrome (HS), a low-incidence condition of uncertain pathogenesis associated with pregnancy hypertensive syndromes, is characterized by hemolysis, elevated liver enzymes and low platelet count. Ruptured subcapsular liver hematoma complicated with hemoperitoneum is an uncommon but very serious condition where early recognition and multidisciplinary management are key to reduce its associated maternal, infant mortality rate. Symptoms are nonspecific, characterized by por epigastric pain, nausea and vomiting; clinical suspicion and appropriate imaging studies are of crucial importance. We report the case of a 36-year-old primiparous woman at 39 weeks of gestation. She was admitted for early membrane rupture, with delivery complicated by retained placenta. During the immediate puerperium she had blood pressure > 140/90 mmHg, epigastric pain and vomiting, which required respiratory and hemodynamic support. An exploratory laparotomy was performed that revealed a massive hemoperitoneum as well as CR in the RLL with multifocal active bleeding. The left liver lobe was macroscopically normal. The patient underwent hemoperitoneum drainage and hepatic packing (HP); biopsy findings were consistent with necrosis. Polytransfusion was initiated with blood products and antihemorrhagic agents.

Using Right-Sided Roll to Improve Reliability of Focused Assessment with Sonography in Trauma: An Eastern Association for the Surgery of Trauma Multicenter Prospective Study.

BACKGROUND: The Focused Assessment Sonography in Trauma (FAST) examination is the standard of care for detecting hemoperitoneum in hypotensive blunt trauma patients. A pilot study demonstrated earlier identification of intra-abdominal fluid via FAST after right-sided roll (FASTeR) when compared with the standard FAST. The purpose of this study was to evaluate this phenomenon prospectively in hypotensive blunt trauma patients. STUDY DESIGN: An Eastern Association for the Surgery of Trauma-approved multicenter prospective trial was performed June 2016 to October 2020 at 8 designated trauma centers. Hypotensive adult blunt trauma patients were included. A traditional FAST examination was performed. After this, the secondary survey logroll for back examination was standardized to the patient's right side. A repeat supine right upper quadrant ultrasound view was obtained. The presence or absence of hemoperitoneum was confirmed by CT scan or intraoperative findings. FAST and FASTeR were compared using receiver operating characteristics. The area under the curve was calculated. RESULTS: A total of 182 patients met inclusion criteria. A total of 65 patients (35.7%) had hemoperitoneum on CT scan or intraoperative findings. The sensitivity of FASTeR was 47.7%, and of FAST was 40.0% (p = 0.019). The receiver operating characteristics area under the curve of the FASTeR examination was 0.717 vs 0.687 for the FAST examination (p = 0.091). CONCLUSIONS: Addition of a right upper quadrant view after right-sided roll does improve the sensitivity of the FAST examination while maintaining the standard positive predictive value. We demonstrate a trend that does not reach statistical significance about the overall accuracy. This multicenter prospective trial was underpowered to reveal a statistically significant difference in the overall accuracy as measured by the receiver operating characteristics area under the curve.

Omental venous malformation: a rare cause of spontaneous haemoperitoneum.

Spontaneous haemoperitoneum is a rare condition with a variety of aetiologies. Regardless of the cause, it is invariably a life-threatening condition that requires urgent diagnosis and management. The most common causes of spontaneous haemoperitoneum include gynaecological, hepatic, splenic and vascular causes. However, here, we present a rare case of spontaneous haemoperitoneum secondary to idiopathic omental venous malformation.Our patient presented with acute onset of right iliac fossa pain, and a CT scan revealed a massive haemoperitoneum. A laparoscopic converted to open laparotomy was performed to diagnose and treat the patient. We discuss the management approach for such patients with spontaneous haemoperitoneum.

Spontaneous intraperitoneal haemorrhage of the gastric vessels.

A male in his 70s presented to the emergency department with sudden-onset abdominal pain and syncope. While in the emergency department, he developed worsening hypotension and anaemia. A CT angiogram was suggestive of abdominal apoplexy (spontaneous intraperitoneal haemorrhage), which was treated successfully with embolisation of the bleeding vessels. Spontaneous bleeding was thought to be related to his initiation of apixaban 1 week previously. The patient made an excellent recovery and was transitioned back to oral anticoagulation.

Spontaneous retroperitoneal haemorrhage from pancreatoduodenal artery (PDA) rupture and associated complications.

Spontaneous retroperitoneal haemorrhage (SRH) is rare. It may present with abdominal or back pain with or without haemodynamic instability. Aggressive resuscitation while investigating the cause of bleeding and providing haemostasis are the standard of care. Subsequent close monitoring is necessary to identify early complications.This study reports three patients who presented to our institution within the last 5 years with SRH from a ruptured pancreaticoduodenal artery (PDA) aneurysm. Each patient had a unique presentation, complications and treatment demonstrating the variability and complexity of SRH. One patient presented with sudden abdominal pain and hypovolaemic shock, underwent angioembolisation and had an eventful recovery. Another patient presented similarly and was treated via angioembolisation but experienced gastric outlet obstruction and obstructive jaundice requiring surgical haematoma evacuation. Another patient had an incidental finding of haemoperitoneum during laparoscopic cholecystectomy that was subsequently diagnosed as SRH resulting from a PDA aneurysm rupture secondary to medial arcuate ligament syndrome.

Rotura aneurismática de la arteria hepática común / Ruptured common hepatic artery aneurysm

RESUMEN Los aneurismas de la arteria hepática son una patología poco frecuente. Cuando son sintomáticos, se debe sospechar un sufrimiento aneurismático y su tratamiento está indicado. Presentamos el caso clínico de un paciente con mal terreno cardiovascular, que consultó por un cuadro clínico de dolor epigástrico, repercusión hemodinámica e ictericia. La imagenología evidenció la presencia de un aneurisma de la arteria hepática común complicado con compromiso del origen de la arteria hepática propia y la arteria gastroduodenal. La presencia de una vascularización arterial hepática "no convencional" con una arteria hepática derecha proveniente de la arteria mesentérica superior, en la angiotomografía, permitió cambiar la táctica quirúrgica haciéndose prescindible la realización de un bypass. Este caso resalta la importancia de determinar en el preoperatorio no solo la extensión del aneurisma, sino también la anatomía vascular hepática a fin de planificar mejor la cirugía, disminuyendo así la morbimortalidad de esta enfermedad.

ABSTRACT Hepatic artery aneurysms are rare. Expanding aneurysms should be suspected in case of symptoms and treatment is indicated. We report the case of a patient with a history of cardiovascular disease who sought medical care due to epigastric pain, hemodynamic instability and jaundice. The imaging tests showed the presence of an aneurysm of the common hepatic artery complicated with involvement of the origin of the proper hepatic artery and the gastroduodenal artery. The surgical approach could be changed due to presence of a "non-conventional" hepatic arterial variant with a right hepatic artery originating from the superior mesenteric artery in the computed tomography angiography as bypass surgery was not necessary. This case highlights the importance of determining the extent of the aneurysm in the preoperative period and the anatomy of the hepatic vessels to better plan the surgery, thus reducing morbidity and mortality of this disease.

Successful laparoscopic management of acute abdominal pain due to spontaneous rupture of subserosal vessels overlying a uterine fibroid: a case report and surgical video.

BACKGROUND: Acute abdomen comprises several emergencies. Hemoperitoneum associated with uterine fibroids, which can present as acute abdominal pain, is rare and difficult to diagnose. Especially, spontaneous hemorrhage from the rupture of the superficial vessels overlying a uterine fibroid is extremely rare, and its diagnosis and management have not been established. CASE PRESENTATION: We report a case of a 55-year-old woman who presented at our hospital with acute abdomen. After performing a computed tomography scan, we conducted a laparoscopic examination and diagnosed hemoperitoneum of ambiguous origin. We treated the patient surgically, performing a laparoscopic myomectomy to remove the origin of the hemorrhage. The patient recovered well. CONCLUSIONS: We report a case of hemoperitoneum of ambiguous origin that was diagnosed laparoscopically and treated by laparoscopic myomectomy to remove the origin of the hemorrhage. Surgeons should rapidly diagnose and manage acute abdominal pain in women with a history of uterine fibroids to prevent severe morbidity or even mortality. Therefore, laparoscopic surgery is recommended in patients with stable hemodynamics.